Instructions for SBAR Communication Tool and Progress Note by hcj


									INTERACT II
Instructions for the SBAR
Communication Tool and Progress Note


The purpose of the SBAR Communication Tool and Progress Note is to improve communication
between nurses and primary care providers (physicians, nurse practitioners, physician
assistants) by encouraging all health care team members to use the same language in
communicating with one another. By creating standardized criteria and clear guidelines for
communication around resident change in condition, more efficient and effective transmission of
important information can occur. The SBAR form can also be used in place of a progress note.

Consistent use of this tool will help your nursing home:
             Communicate effectively with MDs, NPs, and PAs when a resident has had an
                acute change in condition
             Document communication with MDs, NPs, and PAs efficiently

When to use:

                   Prior to contacting the provider when a resident has had a change in condition
                   On residents who have had a change in condition or for shift to shift
                    communication among nursing staff

Who to involve:

Before completing the SBAR, the nurse should check with other staff members who have
regular contact with the resident to obtain an accurate history. Staff members who can provide
useful information about the SITUATION include the CNA, rehab staff, social workers, and
activities staff. A conversation with a family member or health care proxy may also be indicated
to clarify advance directives

Helpful Hints:

                  Before completing the tool, review the resident’s chart (Diagnosis, Medications,
                   Recent Progress Notes from MD/NP as well as most recent nurses notes)

                  Bring form with you when talking to staff and family members about the resident
                   as a reminder about data you are seeking.

                  Refer to Care Paths or Acute Change in Status File Cards if indicated

                  Complete every section of the SBAR prior to calling the MD/NP/PA

                  Have chart available when making the call to the MD/NP/PA

                  Use SBAR and Progress Note to guide your change of shift report

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